Healthcare Provider Details

I. General information

NPI: 1972325215
Provider Name (Legal Business Name): LAKESIDE ABA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19627 FRAMINGHAM DR
GAITHERSBURG MD
20879-1867
US

IV. Provider business mailing address

1500 S DOHENY DR
LOS ANGELES CA
90035-3211
US

V. Phone/Fax

Practice location:
  • Phone: 213-435-9423
  • Fax:
Mailing address:
  • Phone: 213-435-9423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES WILLIAMS
Title or Position: CEO
Credential: PSYD
Phone: 213-435-9423